Universal Health Coverage and Health Equity in West Africa: Tracking Progress Toward SDG 3.8 in Ghana and Liberia

Abstract

Background: Achieving universal health coverage (UHC) remains a key priority for many low- and middle-income countries, yet equity in access continues to be a significant challenge. This study examines the level and distribution of health service coverage in Ghana and Liberia, with a particular focus on wealth- and residence-based disparities, to assess progress toward UHC and Sustainable Development Goal (SDG) 3.8. Methods: A cross-sectional analysis was conducted using the most recent Demographic and Health Survey (DHS) data from Ghana and Liberia. Key indicators related to maternal health, health promotion, environmental health and infectious disease treatment were assessed. Composite indices for protection and treatment coverage were computed. Inequality was measured using the slope index of inequality (SII), relative index of inequality (RII), absolute difference index (ADI) and the urban-rural coverage ratio. Results: Overall, Ghana demonstrated higher coverage in preventive services such as antenatal care (90.6%) and improved drinking water (91.8%), whereas Liberia showed slightly higher treatment coverage for malaria and respiratory infections. However, both countries exhibited substantial pro-rich inequities in skilled birth attendance and insecticide-treated net (ITN) use. In Ghana, a rural advantage was observed in some indicators, likely due to targeted outreach through the Community-Based Health Planning and Services (CHPS) initiative, whereas Liberia displayed mixed urban-rural disparities. The composite coverage index (CCI) was higher in Liberia (77.9%) than in Ghana (63.3%), reflecting recent donor-supported health system investments in Liberia post-Ebola. Conclusion: Despite moderate national coverage levels, significant socio-economic and geographic disparities persist in both countries. Although targeted policies, such as Ghana's National Health Insurance Scheme (NHIS) maternal exemption and Liberia's post-crisis recovery programs, have contributed to localized improvements, inequities in access to essential health services remain. Addressing these disparities is critical for both countries to make meaningful progress toward equitable UHC.